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Burnett County 7410 Co. Rd. K, 8102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. p <br /> m m <br /> 0 <br /> OWNER(Please Print) Co actor Surve r r Agent o. L- <br /> ('. v <br /> iX �� <br /> Ad ss Addrejq -- (f) <br /> City,State,Zip Coe City, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading L <br /> Addition Moving o <br /> Sanitary Camping Unit 0 <br /> 0 <br /> Privy Subdivision <br /> r <br /> Structure Use: v <br /> (family homelcabin,garage, addition, etc.) o a <br /> a <br /> Directions for plot plan drawing: + <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N), <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield(DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream - if within 300 ft. <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provide legal land description. <br /> 0 <br /> PLOT PLAN 3 <br /> a N <br /> Z Q <br /> 3- <br /> U, <br /> /, a 1 -70 <br /> I1 , <br /> to At <br /> rj:� Gam, o' <br /> Z <br /> Z <br /> D <br /> a < °' 00 <br /> y[ 2 0 0 M <br /> Z o <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that lam responsible for the detail and accuracy of all = : m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit. I further accept all liability which may be a result of the County of Burnett relying on this information I am providing � a <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. 'rp <br /> T G: <br /> 0 <br /> o <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) C o o <br /> ZONING ADMINISTRATOR �A _g E=- P <br /> <' N N c N +N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED y�V V V o o v, <br /> aaQooaom/1 <br />